The social organisation of practice nurses' knowledge utilisation : an ethnographic study

In the study reported in this thesis a conceptual framework drawing on a range of social, organisational and educational theories was used to underpin an investigation into the social organisation of practice nurses’ knowledge utilisation. Particular attention was paid to the concept of ‘clinical mindlines’. Changes in healthcare delivery, particularly in primary care, have resulted in changes to practice nurses’ roles. Macro level policy has focused increasingly on standardisation of care within the primary care environment, specifically in relation to management of chronic/long term conditions. Practice nurses have additionally taken on roles that include diagnostic and treatment elements for which they were not prepared for in their initial training. Set against this background ethnographic data were generated relating to meso level organisation of knowledge utilisation in two study sites. Interviews, observation and documentary analysis of available knowledge sources including guidelines and protocols were used to generate data relating to how knowledge is accessed and subsequently used at the micro level of the clinical patient encounter. Findings illustrated that a mixture of organisational and individual factors impacted on knowledge utilisation. Practice nurses used a combination of knowledge which they applied within the context of the individual patient encounter. This was accessed partly through their ‘mindlines’ developed from education, clinical experience and social learning and partly through accessing a ‘bricolage’ of knowledge which included seeking advice from a variety of sources. Specific elements of note were enthusiasm towards evidence based practice, both amongst the nurses and at practice level and a supportive organisational culture towards continuing education and sharing of knowledge. Standardisation embedded into computer templates that guided the chronic disease management consultations had both a positive and negative influence, positive in its focus on improving evidence based care, whilst negative in promoting template driven care that takes little account of individual patient need. Organisational elements constraining effective knowledge dissemination and use included information being disseminated to the practice nurses through vertical rather than horizontal networking; professional training that had not prepared nurses to deal with uncertainty; the part time nature of the practice nurse role; limitations in accessing evidence in ‘real time’ and lack of applicability of evidence to all patient scenarios.